Efficacy of an Attachable Silver Impregnated Subcutaneous Cuff for the Prevention of Catheter-Associated Infections in Patients on Chronic Maintenance Hemodialysis

Charles J. Diskin, MD, Hypertension Nephrology and Dialysis Clinic, 121 North 20th Street, Opelika, AL 36802 (USA) Dear Sir, Infection was noted to be a common and serious complication of renal failure long before the development of maintenance dialysis [1] and was often listed as the chief cause of death [2]. Even now, sepsis remains a leading cause of morbidity and mortality in patients with chronic renal failure [3, 4] despite our technological success. In our population of patients with end stage renal disease (ESRD) in Opelika, Alabama, sepsis was the leading cause of mortality between 1982 and 1987, being responsible for 27% of all our ESRD deaths. That was consistent with reports from other centers that have established infection as the cause of deaths in 11-38% of all patients on hemodialysis [3, 5-8]. The reasons for the high morbidity and mortality have in the past been attributed to altered host defenses since uremia promotes defects in cellular [9-14] and humoral immunity [15,16]. However, we have previously reported that the serum bacteriocidal activity in hemodialysis patients [17] is generally normal and most studies suggest that the principal cause of sepsis in those patients is due to the loss of the integrity of the skin as a defense barrier to bacterial invasion of the blood stream [5] that accompanies the need for a hemodialysis vascular access [18]. Over the last 15 years the widespread use of subclavian catheters for temporary vascular access has further violated that barrier and only increased the incidence of sepsis. Bacteremia has been reported in 15-55% [19,20] of all subclavian hemodialysis catheters. One group has reported 77% of all admissions for sepsis in the first 3 months after the initiation of dialysis to be related to subclavian catheter use [21]. In 1989 sepsis was responsible for 27% of our hospital days with 75% of hospitalizations for sepsis related to an indwelling subclavian catheter. At that time an attachable silver-impregnated cuff had been shown to decrease the incidence of infections in Swan-Ganz and nondialysis-associated subclavian catheters [22-24]. We therefore devised the following study to evaluate the efficacy of these cuffs for the reduction of catheter-associated sepsis in hemodialysis patients. During March 1990 the first 4 hemodialysis patients requiring a temporary vascular access received a subclavian catheter with an attachable silver-impregnated cuff (Vita-CuffTM; fig. 1). Since intrajugular catheters have been associated with a significantly higher risk of infection than subclavian catheters [25], all patients requiring an intrajugular catheter were excluded. Similarly, all patients with a history of an active infection, prior transplantation or current therapy with immu-nosuppressive medication were excluded. All patients had serum ferritin values of greater than 100 but less than 500 mg/l. These patients were then followed in the chronic hemodialysis